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Home My WebLink AboutPermit Mechanical 1993-7-26 ) YOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location: \ \ C\-\ Q c\\)\ \\~ ~r) Asses~or\5ap II: \ VJ~(:)?-' 'd lift.' \. ........ .Tax Lot Ovner:~ ()~Z\ QQ ,eJ\(\f() f1 SJ, } Address: I 14{Jl (_~ \ j\ \00. Q -f; - Phone II: City: b0.QJ(l~ Q' Q IjJ State: (~lQ1\tyr\ Value of YoJd Stove/pe(j~Stove/Insert: \~~ ~ (please circle appropriate appliance) ). . II: D\n(X) Y\4 \ - ~( rA~\ Zip: Or)4f1 () Preliminary.Inspection is $15.00 (prior to installation of insert) Yood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance\\ ~^7~^ s~~~UrCharge. Type of Inspecf\on ReqUested:U-~ti tiU\ f\l {\(\\~ ~J Contractor:\' A!O.~ ~ l"+~ 1~\1\ 0 \r~ Address:, '1 () i<' \\~ Y\ 0 I .~ ~0B{1 Phone 1I:.~41Q-~ City: ~'X'.\,QJ\Q j Cj State: LtJJ.Q f'1fJr\ Zip: L1l4D \. Construction CcCltractors Registratiton II: '-1 \"'JCuN Expires: ,\. I.~ . q + By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I vas provided vith the Yood Stove Safety information for vood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I ;elSO derstand that if I am requesting a preliminary inspection, the vall covering ma b required to be removed. ! A-<(A /~J , /7) "'~.A V - ~gnature Date FOR OFFICE USE REQUIRED INSPECTION(S): ~DSTOVg/PELLET/~~ ~~ PRELIMINARY Date of Application: I-J. TIT () .Lt~ Job II: q 00fl Q ~ Total Amount Collected: c!J ~ .Il SAC Receipt II: q (O~ C) Issued By: f:f)\[)(l_J Checked for Delinquencies: Checked for Historical Status: .,' ,.I~.. . . Permit No: C\6D~ flV Address: \ \ ~ 4-lo ~\)\~ ~ (\(\ \LA , Issued by:1:f\\j)~ '} Date: 'J .c9W) FOR OFFICE USE ONLY STATEMENT: INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES Note: Oregon Law, ORS 701.055(4), requires residential construction permit applicants who are not registered with the Construction Contractors Board to sign the following statement before the building permit can be issued. This state- ment is required for residential building, electrical, mechanical, and plumbing permits. Licensed Architect and Engineer applicants, exempt from registration under ORS 701.010(7), need not submit this statement. This statement will be filed with the permit. Fill in~ thnpPlicable blanks, and initial boxes 1 and 2, and either box 3A or 3B: 1. I T l I own, reside in, or will reside in the completed structure. I 2. . I I I I understand that I must register.as a construction contractor if the structure is sold , Il or offered for sale before~upon ,completio~_ \ 3. A.~ My general contractor is <\0 b9 r T ~--\-n Q ~ ( Contractor registration number) '7~ - I will instruct my general contractor that all subcontractors who work on (he struc- ture must be registered with the Construction Contractors Board. OR 3. B.I I I will be my own general contractor. If I hire subcontractors, I will hire only subcontractors registered with the Construc- tion Contractors Board. If I change my mind and do hire a general contractor, I will contract with a contractor who is registered with the Construction Contractors Board and I will immediately notify the office issuing this building permit of the name of the contractor. I hereby certify that the above information is correct and that I have read and understand the Information Notice to Property Owners about Construction Responsibilities on the reverse ~f this form. t~~~ ' 7Y},,~ Signature o'r\:>;;;mit Applicant Date CONSTRUCTION CONTRACTORS BOARD . 0244J 6/91 WHITE COPY TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT . . INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES _..... I.. Ii NGrE:: This Information Notice to Property Owners About Construction Responsibilities was developed by the Construction Contractors Board in accordance with ORS 701.055(5), passed .by the 1989 Oregon Legislature. If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and areas of concern. ' EMPLOYER RESPONSIBILITIES: I' If you hire person~ not registered with the Construction Contractors Board to do labor in constructing or assisting in the construction or improvement of a residential structure, you will, in most instances, be ruled to be an "employer" and \he people you hire will be "employees". As the employer, you must comply with the following: Oregon's Withpolding Tax Law; As an employer, you must withhold income taxes from employee wages at the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Oregon Department of Revenue at 378-3390. Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more .information, call the Oregon Employment Division DHR at 378-3224. Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insurance feir your employees. If you fail to obtain workers' compensation.insurance, you may be subject to penalties and will be liable for all claim costs if one of your employees is injured on the job. For more inf?rmation, call the Workers' Compensation Division DIF at 373-7434. U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be liable for the t~x paym(;lnt even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service at 221-39150. ' OTHER RESPOI')lSIBILlTlES AND AREAS OF CONCERN: Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirerJ].ents that may be brought to your attention through inspections. Liability.and Property Damage Insurance: Contact your insurance agent to see if you have adequate insurance coverage for accidents and omissions such as falling tools, paint overspray, water damage from pipe punc- tures, fire. or work that must be re-done. Time to Supervise Employees: Make sure you have sufficient time to supervise your employees. i, Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform the required inspections. If you have additional questions, write to: Construction Contractors Board 700 Summer SI. NE, Suite 300 Salem. OR 97310-0151 Phone 503.378-4621 0244J 10/24/89 .